Peninsula Counseling Center v. Rahm

719 P.2d 926, 105 Wash. 2d 929, 1986 Wash. LEXIS 1196

• Court: Washington Supreme Court
• Decided: May 29, 1986
• Docket: 52045-3
• Status: Published

Opinions

Goodloe, J.

In 1982, the Legislature passed the Community Mental Health Services Act (RCW 71.24). This act establishes a comprehensive mental health program which provides patients access to state subsidized mental health facilities. Because of the amount of state funding involved, the act specifically attempts to ensure " [accountability of services through state-wide standards for management, monitoring, and reporting of information ..." RCW 71.24-.015(2). This requirement is especially important because the State, pursuant to a recent change in administration of federal funding, receives "block" grants from the federal government, and these grants are contingent upon the State's "use [of] the funds provided only for the purposes specified in the approved [state] application". Significantly, the State must "establish such fiscal control and fund accounting procedures as may be necessary to assure proper disbursement and accounting of Federal funds paid to the [state]." 42 U.S.C. § 300x-l(a)(2).

Although the State has not had any funds disallowed, the Department of Social and Health Services (DSHS) has been concerned about the current reporting system, and has attempted to implement a more detailed accounting system for patients receiving state and federal aid. Currently, DSHS receives aggregate information from the mental health centers on the number of clients the centers treated and the service units the centers provided, without actually finding out the names of the patients. Thus, DSHS is not aware whether a patient receiving mental health services at one center is also receiving services at another center.

Under certain limited circumstances, DSHS will receive the names and look at the actual files of mental health patients. During an audit of the mental health center, the auditors may check an individual's records to ensure the services have been provided, but the auditors are bound by confidentiality agreements and the patients may have their names obliterated when their files are being checked. Furthermore, to determine eligibility for Medicaid, patients may make direct disclosures to the State. The trial court found, however, that these disclosures to the State "differ substantially in degree and quality" from the diagnosis and treatment based disclosures. Clerk's Papers, at 19.

The new Community Mental Health Services Act, and the regulations enacted to implement it, would increase the amount of disclosure by certain types of patients because of the requirement that DSHS

[d]evelop and maintain an information system to be used by the state and counties which shall include a tracking method which allows the department to identify mental health clients' participation in any mental health service or public program. . . . Confidentiality of client information and records shall be maintained [pursuant to various statutes] . . .

RCW 71.24.035(4)(h). DSHS adopted two regulations, WAC 275-56-055 and WAC 275-56-060, which required mental health centers to provide specific information to DSHS for "priority patients" (patients meeting a statutory definition of acutely ill, chronically mentally ill, or seriously disturbed, RCW 71.24.025), including the patient's name, birthdate, places to which the center referred the patient, and classification of the patient's diagnosis. DSHS will not use this raw data in subsequent evaluations (unless individual contact became necessary), but will instead create a "PICCODE" which will uniquely identify each patient by code. Allegedly only four people will have access to the raw data; the rest will use the PICCODE.

The data will be used for two different purposes. First, DSHS will develop two data bases called CMHIS (Community Health Information System) and CCIS (Common Client Identification System) to obtain unduplicated lists of patients using the state funded system, and to help plan for future development: of state mental health care. A person would remain in the data base for 5 years after treatment.

Secondly, chronically mentally ill patients also would be required to participate in a tracking program. Tracking would help determine if mental health funds were effectively spent and would help ensure patients received continuity of care. The tracking system requires county health facilities to give the State the name of any patient the facility discharged or referred to another facility. After the patient has been discharged and DSHS has been notified, no further action is taken, WAC 275-56-060(1), although the patient also remains on the data base for 5 years. If the patient was referred, the receiving facility must tell the State whether or n,ot the patient arrived. WAC 275-56-060(2). If the patient did not arrive, the receiving agency may take steps to contact the patient, including the possibility of a phone call or a visit.

Peninsula Hospital, the Washington Mental Health Council, Seattle Counseling Service, and two unidentified patients brought a suit to enjoin DSHS from carrying out these tracking systems (known overall as CMHTS — Community Mental Health Tracking System). They alleged these disclosures of name and diagnosis to the State violated the patients' rights to privacy under the United States and Washington State Constitutions. Furthermore, the respondents assert that the effect of requiring disclosure would have a chilling effect on the mental health care system and would result in patients declining needed mental health care. Finally, the respondents claim that DSHS could implement a system which "tracked" patients and provided more detailed records through less intrusive means. Specifically, DSHS could have the individual health centers encode the patient's name, birthdate, sex, diagnosis, etc., and send that code, rather than the raw data, to the State.

The trial court judge agreed with respondents and granted their prayer for a preliminary and permanent injunction. The trial court also granted the respondents attorney fees of $30,000 pursuant to 42 U.S.C. § 1988. The State and DSHS have appealed to the Court of Appeals, which certified this case to this court.

Respondents have asserted that they have a constitutional right to privacy which would preclude the county health authorities from giving patients' names and diagnoses to DSHS. Respondents base this right on the personal nature of the information DSHS is requesting. Specifically, the respondents believe that the fact that a patient is undergoing treatment for mental illness is confidential, and this confidentiality is required in order to have psychiatric treatment succeed.

The United States Supreme Court has recognized that a right to privacy exists in certain situations. Meyer v. Nebraska, 262 U.S. 390, 67 L. Ed. 1042, 43 S. Ct. 625, 29 A.L.R. 1446 (1923); Roe v. Wade, 410 U.S. 113, 35 L. Ed. 2d 147, 93 S. Ct. 705 (1973). It is equally true, however, that the United States Constitution does not guarantee a general right to privacy. Katz v. United States, 389 U.S. 347, 350, 19 L. Ed. 2d 576, 88 S. Ct. 507 (1967). Rather, this right has been limited to a core group of privacy rights which receive constitutional protection. These privacy rights fall into two different categories. First, individuals should be allowed the autonomy to make certain fundamental decisions without government intrusion (abortion, contraception, education, etc.). Secondly, they should also be protected from disclosure of certain personal matters to the government. Whalen v. Roe, 429 U.S. 589, 599-600, 51 L. Ed. 2d 64, 97 S. Ct. 869 (1977).

A variety of cases dealing with psychiatrist-patient relationships have emphasized the need for confidentiality between the psychiatrist and the patient. Caesar v. Moun-tanos, 542 F.2d 1064 (9th Cir. 1976); In re Lifschutz, 2 Cal. 3d 415, 467 P.2d 557, 85 Cal. Rptr. 829 (1970); In re Zuniga, 714 F.2d 632 (6th Cir. 1983). Ample evidence, both from prior cases and from testimony at this trial, has shown that disclosure of communication between a psychiatrist and a patient would deter a small but significant number of individuals from seeking much needed care, and the potential disclosure would prevent other individuals from participating fully once therapy began. Hawaii Psychiatric Soc'y v. Ariyoshi, 481 F. Supp. 1028 (D. Hawaii 1979).

Nevertheless, this need for confidentiality does not necessarily mean that a statute requiring disclosure would violate the federal constitution. In Whalen v. Roe, supra, certain doctors challenged a New York statute requiring doctors to send a copy of a prescription as well as the name, address, and age of a patient to the state health department, when the prescription was for certain potentially abusable types of drugs. The disclosure of the patient's name, even if it intruded into the confidential doctor-patient relationship, and even if it would deter some patients from obtaining medically beneficial prescriptions, did not raise the privacy interests to a constitutional level.

[Disclosures of private medical information to doctors, to hospital personnel, to insurance companies, and to public health agencies are often an essential part of modern medical practice even when the disclosure may reflect unfavorably on the character of the patient. Requiring such disclosures to representatives of the State having responsibility for the health of the community, does not automatically amount to an impermissible invasion of privacy.

(Footnote omitted.) Whalen, at 602. Other cases agree that disclosure of certain medical information does not, in itself, rise to constitutional dimensions. Department of Social & Health Servs. v. Latta, 92 Wn.2d 812, 601 P.2d 520 (1979) (disclosure of minor's medical records pursuant to Medicaid audit not a constitutional privacy violation); In re R., 97 Wn.2d 182, 641 P.2d 704 (1982) (questioning whether constitutional privacy right applies to statutory waiver of physician-patient privilege in involuntary detention proceedings); Schachter v. Whalen, 581 F.2d 35 (2d Cir. 1978) (disclosure of Laetrile prescriptions to state authorities permissible).

However, certain more intrusive disclosures to government authorities have violated the constitutional right to privacy of the individuals involved. In Hawaii Psychiatric Soc'y, the federal District Court held that comprehensive disclosure of patients' files and psychological profiles pursuant to an audit of medical records did violate the patients' right to privacy. The court held "[t]he unique personal character of the disclosures distinguished the case from Whalen." Hawaii Psychiatric Soc'y, at 1044. It was apparent that the court was concerned that the amount of disclosure required far exceeded the amount needed for an audit. In Thorne v. El Segundo, 726 F.2d 459 (9th Cir. 1983), a police department asked intimate questions about an applicant's sex life. Although the questions were supposedly needed in order to maintain the morale and integrity of the police force, the court held they were far more intrusive than necessary, and violated the applicant's right to privacy.

The theme in all these cases is the same. While disclosure of intimate information to governmental agencies is permissible if it is carefully tailored to meet a valid governmental interest, the disclosure cannot be greater than is reasonably necessary. See further McKenna v. Fargo, 451 F. Supp. 1355, 1381 (D.N.J. 1978); United States v. Westinghouse Elec. Corp., 638 F.2d 570, 578 (3d Cir. 1980). We therefore must decide whether DSHS has required disclosure of more information than is reasonably needed in order to maintain an efficient auditing and tracking system.

We believe it has not, and therefore reverse the lower court's findings. The federal government has specifically required adequate accounting systems to ensure federal funds are actually spent in treating mentally ill patients. Furthermore, without question the State has an interest in maintaining adequate mental health facilities and ensuring care for individual patients. See Tarasoff v. Regents of Univ. of Cal., 17 Cal. 3d 425, 551 P.2d 334, 131 Cal. Rptr. 14 (1976). These centralized records are kept strictly confidential and include no more than the patient's name and diagnostic code. They are not overbroad and are carefully tailored to meet the State's legitimate, and laudable, interests.

We recognize that the respondents presented evidence that the individual health centers could encode the information before sending the code to DSHS. While the trial court found this code could be used to obtain an unduplic-ated count of patients as well as tracking patients who are given referrals, such a system undoubtedly would be more cumbersome and error prone than having one centrally located encoding system. Although we recognize the importance of the impression of absolute confidentiality in these cases, it is nonetheless true that, unless individual contact becomes necessary, only a handful of DSHS officials will have access to the raw data. These officials will be subject to civil penalties for violation of the confidentiality of this information. RCW 71.05.390. In In re Zuniga, supra, this type of information was disclosed to a grand jury investigating a doctor's medical billing records despite his objections without violating the patients' right to privacy. The secrecy of the grand jury proceedings, coupled with the limited disclosure required, justified such an intrusion. We believe the same rationale is controlling here.

We therefore hold that the trial court erred when it granted a preliminary and permanent injunction prohibiting DSHS from imposing its new regulations. While we realize that the respondents present Const, art. 1, § 7, and due process arguments for upholding the trial court’s verdict, we find them equally unpersuasive. The limited nature of this disclosure, carefully tailored to meet the legitimate goals of the State, justifies the resulting intrusions into the admittedly private affairs of the patients.

Respondents brought this action in part under 42 U.S.C. § 1983 et seq. Pursuant to 42 U.S.C. § 1988, the prevailing party in a civil rights case may receive attorney fees. As we have reversed the trial court's decision, respondents are not the prevailing party and, therefore, cannot receive attorney fees pursuant to 42 U.S.C. § 1988.

We remand this case to the trial court to enter an order denying the respondents' request for a preliminary and permanent injunction.

Dolliver, C.J., and Utter, Dore, Andersen, Callow, and Durham, JJ., concur.